Job Summary

The Insurance Specialist serves as a key contact for patient questions related to insurance claims, denials, coding, re-determinations, attorney settlements, and retro authorizations. The Insurance Specialist handles resolving credit balances and pay discrepancies, reviewing prior billing activity and correcting errors. The Insurance Specialist serves as a subject matter expert on payer guidelines, focusing on underpayment recovery, aged denial resolution, and supporting claim adjudication.

Minimum Job Qualifications

• Licensure or other certifications: Certified Patient Account Representative (CPAR) and Certified Professional Biller (CPB) or Certified Professional Coder (CPC)

• Educational Requirements: High School Diploma or GED.

• Minimum Experience: Minimum 3 years of medical billing and/or medical coding experience.

• ​Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:

• Preferred Educational Requirements:

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Knowledge of Revenue Cycle functions, including registration, coding/charge posting, payment posting, and financial assistance.

• Thorough knowledge of patient collections, billing regulations (governmental and commercial), denial follow-up procedures, and interpreting EOBs to resolve posting and billing issues.

• Personal computer proficiency to include all programs necessary to perform job duties and ability to toggle between systems efficiently.

• Strong listening, problem-solving, and customer service skills with the ability to remain calm and professional in stressful situations 

• Excellent verbal and written communication skills with strong telephone proficiency. 

• Ability to work independently within guidelines.

• Thorough knowledge of HIPAA regulations to protect patient health information.

Essential Tasks and Responsibilities

• Verifies and updates patient insurance coverage.  Rebills claims as appropriate. Reviews and updates patient accounts and insurance coverage, rebilling claims as appropriate. 

• Meets or exceeds required quality, and productivity performance standards as determined by SPRC leadership.

• Follows scripting and departmental guidelines to ensure quality service 

• Researches and resolves patient inquires via phone and electronic messages, deescalating complaints to improve the billing experience, and escalating to leadership when appropriate 

• Attends all Weekly/Monthly/Quarterly/Annual department and Department Meetings.

• Works with patient/guarantor to find/add insurance, third-party sponsorship, and settlement. 

• Maintains an understanding of health insurance and EOB's, collection processes and techniques, and NGHS Financial Assistance Programs.

• Adapts to frequently changing atmosphere including organizational and technological changes.

• Performs other duties as assigned, including but not limited to work queues, itemized statement requests, providing Detail Bills, 1500s and Ubs

• Promotes and contributes positively to the teamwork of the department by assisting coworkers, contributing ideas and problem-solving with co-workers and helps identify trends affecting patient billing and customer satisfaction.

• Liaises with patients and payers to resolve insurance billing issues, obtain required documentation, and review EOBs for payment accuracy. 

• Contacts insurance companies via telephone and websites to reprocess aged facility and professional claims.

• Identifies and corrects posting errors and underpayments or denials that are still within the appeal window, resubmitting claims for late charges and other issues.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Heavy, Constantly 66-100% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Constantly 66-100%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding